Please use this form for all Insurance Applications.

Is the insurance for a child? *

Adult Application

Child Application

PERSONAL INFORMATION

First Name

Last Name

Phone *

Email *

SIN *

Country of Birth *

Date of birth *

Address *

Postal code *

How long at this address? *

Child 1 Name

Child 1 Date of Birth

Child 2 Name

Child 2 Date of Birth

Child 3 Name

Child 3 Date of Birth

EMPLOYMENT AND NET WORTH

Employer *

Employment Status *

Employer Address *

Income per year *

Years / Months with Current Employer *

Employment - Industry *

Job Title *

Previous Employer (If less than 5 years with current employer)

Years / Months with Previous Employer

Mortgage Bank / Landlord *

Mortgage Balance / Rent Payment ($0.00 if Not Applicable) *

Have you ever declared bankruptcy? *

Yes

Assets *

Liabilities *

LIFESTYLE QUESTIONS

Smoking Status *

Height and Weight *

Weight gain/loss in the last 12 months?

How often do you drink? *

Do you participate in hazardous activities? *

Yes

Family Doctor / Clinic *

Family Doctor Address *

Family Doctor - Date of Last Visit *

Family Doctor - Purpose of Last Visit *

BENEFICIARIES AND INSURANCE HISTORY

Marital Status *

Beneficiaries Names, Relationship, Birthdates (mm/dd/yyyy), Percentage(s) *

Backup Beneficiaries

Have you ever had an application for insurance Declined, Postponed, or Rated? *

Yes

Additional Notes

Primary ID / Drivers Licence

Secondary ID / Other Government Issue ID

Void Cheque